Magnolia Place of Saxonburg.

“Resident #1's annual medical evaluation had a blank immunization area, failing to meet the requirement for complete annual medical evaluations.”

“Resident #2's Ketoconazole cream administration on 1/6/26 at 6:00 p.m. was not initialed on the medication administration record. Additionally, prescribed medications for residents #2 and #3 on 12/16/25 were not administered but were falsely documented as administered by staff person A.”

“Multiple residents (#2, #3, #4) had prescribed medications that were not administered as directed by the prescriber on various dates (12/16/25 and 1/5/26), including Bumetanide, Metformin, Potassium Cl, Eliquis, Ketoconazole cream, and Mirtazapine.”

“Resident #1's assessment did not address resident care needs and contained inaccurate information regarding ambulation ability, failing to meet assessment requirements.”

“Resident #1's support plan was undated and did not indicate when the support plan was finalized, failing to meet the requirement for timely revision of support plans.”

“A resident in the secure dementia care unit struck another resident in the head and legs, resulting in a red mark above the eye and scrapes on the legs. Staff had left the agitated resident alone in the shared room during incontinence care.”

“Fire drill records did not include evacuation times in minutes and seconds for drills conducted on 11/26/24, 6/27/24, 4/30/24, and 1/29/24.”

“Fire drills conducted from January 2024 through December 2024 failed to use alternate exit routes, with all drills recording only "Safe Area" as the exit route used.”

“An uncovered/open garbage bag half filled with refuse was found in the kitchen located on the garden's unit. Trash in kitchens and bathrooms shall be kept in covered trash receptacles that prevent the penetration of insects and rodents.”

“Resident #1 had no fitted sheets on bed. Each resident shall have clean and in good repair bed linens in the bedroom.”

“The common bathroom located next to the nurse station in the memory care unit had no toilet paper. Individual toiletry items including toothpaste, toothbrush, shampoo, deodorant, comb and hairbrush shall be made available to residents.”

“The fire safety diagram on the memory care unit indicated two sets of double fire safety doors present in the middle of the long hallway, but only one set of double fire safety doors is actually present. Emergency evacuation diagrams must accurately show corridors, line of travel to exit doors, and location of fire extinguishers and pull signals.”

“The fire extinguisher next to the laundry room on the memory care unit had no attached documentation of an annual inspection conducted by a fire safety expert. Fire extinguishers shall be inspected and approved annually by a fire safety expert with the date of inspection on the extinguisher.”

“The doorway in the rear of the memory care unit's dining room had signage indicating the egress as an exit, however, this point of egress was not an exit. Exit signs bearing the word 'EXIT' in plain legible letters shall be placed only at actual exits.”

“Resident #2 is prescribed insulin subcutaneously twice daily with instructions not to mix with other insulin, however the medication's label indicated inject 5 units subcutaneously twice a day without the complete instructions. Prescription medication labels shall include the prescribed dosage and instructions for administration.”

“A medication administration record indicated a blood glucose level of 202 for Resident #2, however the resident's glucometer indicated a different blood glucose level at the previously specified date and time. The home shall develop and implement procedures for the safe storage, access, security, distribution and use of medications and medical equipment by trained staff persons.”

“The support plan for resident #1 does not document the care services provided by home health services or how the home will meet the resident's need for wound/skin care.”

“Staff person A was observed holding a resident by the forearm and yelling while trying to pull the resident out of a bedroom, causing the resident to shake and experience fear. The resident sustained a reopened skin tear and a small fingernail-like tear on the left forearm.”

“Staff person A smacked a resident on the right hand with the back of staff's hand and made a dismissive remark after the resident pushed staff away during a bedtime care routine.”